Knowledge Brief Health, Nutrition and Population Global Practice BASIC PROFILE OF EARLY CHILDBIRTH IN PAKISTAN Chata Malé and Quentin Wodon March 2016 Child Marriage Series with Education Global Practice KEY MESSAGES:  Measures of early childbirth are moderate in Pakistan. The share of women ages 18-22 who had a child before 18 is 6.8 percent, and it has decreased over time. The share of girls who had a child before the age of 15, at less than one percent, has also decreased.  Early childbirth is associated with lower wealth, lower education levels, and employment without cash earnings. These are however only correlations, not necessarily causal effects. In order to design programs and policies to reduce the Box 1: Brief and Series Primer prevalence of early childbirth, information is needed on its How is child marriage defined? Child marriage is defined as a trend over time, where it is most prevalent in a country, marriage or union taking place before the age of 18. and what the characteristics of girls giving birth early are. Why a series on child marriage? Child marriage has Measuring early childbirth is needed to inform policy. significant negative impacts – not only for girls, but also for a range of development outcomes. Demonstrating these impacts Early pregnancy and childbirth are important issues in will assist governments and others to make the case for intervening to reduce the practice. many countries. Early childbirth is associated with higher health risks for the mother and the child as well as higher What are the topics discussed in the series? The series fertility. It may lead girls to drop out of school. In most looks at the impacts of child marriage on health, population, countries, most early childbirths take place after marriage. education, employment, agency, and violence, among other But in some countries, it may also often take place without outcomes. The welfare, budget, and non-monetary costs of child a marriage or union. To reduce the prevalence of early marriage are estimated. Legal/institutional aspects and options childbirth, specific programs and policies are required, for to reduce the practice are also discussed. which basic information is needed. Using techniques inspired by the poverty literature, this brief provides a What is the question asked in this brief? The question is: How widespread is early childbirth, not only in terms of the share basic profile of early childbirth in Pakistan. The brief of girls affected by it, but also in terms of how early births occur? documents the extent of early childbirth, its trend over time, in which areas it is most prevalent, and what some How is the question answered? Measures and a profile of of the characteristics of the girls affected by early early childbirth inspired by the literature on poverty are provided. childbirth are. The brief is part of a series of standardized briefs on this topic for several countries. Page 1 HNPGP Knowledge Brief  Seven percent of women have an early childbirth. The consequences of early childbirth for girls and their children are not the same whether girls have a child at 12 The analysis relies on data from the latest Demographic or 17. Measures inspired from the poverty literature help and Health Survey (DHS) for Pakistan for 2012-13, the in capturing how early girls have children (see the annex). latest DHS available. Table 1 provides basic statistics on The headcount (H) measures the share of girls with an the age at first birth. Two samples are considered: women early childbirth. The early childbirth gap (ECG) measures ages 18 to 22, the youngest age group that can be used the “depth” of early childbirth, taking into account how to measure early childbirth1 and women 18-49 (the early girls have children. The squared gap (SG) puts even women’s questionnaire in the DHS collects data for more weight on the girls who have children very early. women up to age 49). Just under seven percent of women have their first child before 18, and only half a Early childbirths have decreased over time. percent do before 15. There is a decrease in the mean age at first birth between the 18-49 sample and the 18-22 Table 3 provides trends over time in the measures of sample. This is in large part because many women ages early childbirth inspired by the poverty literature. Consider 18 to 22 did not yet have a birth, but it also suggests a decline in child marriage over time as discussed below. first the age group 18-22. In that age group, just under seven percent of women had their first child before the Table 1: Age at First Birth for Women (%) age of 18 (6.8 percent for the 18-22 age group). The early 18-22 years 18-49 years childbirth gap (CBG) is at 0.7 percent and the squared No Birth 78.0 34.1 gap (SG) at 0.1 percent for that group. By estimating the 18 or Above 15.2 53.4 same measures on older groups, the table provides the 12 0.0 0.2 trend in early childbirth over time. There has actually been 13 0.2 0.3 a large decrease over time in early childbirth. The same is 14 0.2 0.9 observed when considering very early childbirth before 15 1.0 2.2 the age of 152. 16 1.7 3.6 17 3.6 5.4 Table 3: Trend in Early childbirth (%) Total 100.0 134.1 18 years 15 years Mean age at first birth 18.4 20.9 H CMG SG H CMG SG Source: Authors’ estimation. All 18-49 years 12.5 1.4 0.2 1.4 0.14 0.02 Age group Most early childbirths take place after marriage. 18-22 years 6.8 0.7 0.1 0.5 0.05 0.01 23-30 years 11.7 1.3 0.2 1.5 0.15 0.02 In Pakistan, there is a strong relationship between the age 31-40 years 15.5 1.7 0.3 1.7 0.15 0.02 at first birth and the age at first marriage as communities 41-49 years 18.6 2.2 0.3 2.1 0.22 0.03 do not look favorably at births out of wedlock. Table 2 Source: Authors’ estimation. Values rounding to 0.0 not shown. displays the shares of girls with an early childbirth according to three categories in terms of the timing (or The incidence of early childbirth in Pakistan in 2012-13 absence) of marriage among married women ages 18-22. was lower than that observed 25 years ago. There has Most early childbirths take place after marriage, hence been a decrease over time in how early girls have delaying the age at marriage is essential to avoid early children. childbirth. Girls are more likely to have children early if they live Table 2: Marriage and Early Childbirth, Age 18-22 (%) in rural areas and are from poorer backgrounds. Share Early childbirth before getting marriage 1.7 Early childbirth in the same year as marriage 23.8 As expected, early childbirth is much more prevalent in Early childbirth at least one year after marriage 74.5 rural than in urban areas. There are also large differences Total 100.0 between regions, with the lowest measures observed in Source: Authors’ estimation. the capital city of Islamabad (ICT), and the highest measures observed (according to the headcount index with the 18 years threshold) in Khyber Pakhtunkhwa, Balochistan, and Gilgit Baltistan. Early childbirth is less prevalent in Punjab and Sindh. The ranking of the regions 1 Early childbirth measures must be estimated on the population older than 18, because some younger girls who did not yet have a child by 18 could still have a child by the time they reach 18. It 2 is best to measure early childbirth as early as possible after the Note that the various measures have standard errors (not age of 18 to provide data on conditions as current as possible, shown here to save space). While some of the differences in the which is why the age bracket 18-22 is used here. trends over time are statistically significant, some are not. Page 2 HNPGP Knowledge Brief  terms of the measures obtained with the 15 and 18 in their first child. The causality goes the other way as well, years thresholds tends to be similar. as the ability to pursue one’s education may help delay the age at marriage and thereby the age at first birth. As Table 4: Early childbirth by Location, Age 18-22 (%) seen in table 6, early childbirth measures are strongly 18 years 15 years correlated with education levels. The same is observed H CMG SG H CMG SG when considering literacy where three categories are All 18-22 years 6.8 0.7 0.1 0.5 0.05 0.01 considered: the woman cannot read at all, can read part Region of a sentence, or can read a full sentence. Punjab 5.7 0.5 0.1 0.1 0.02 - Sindh 5.7 0.6 0.1 0.3 0.04 0.01 Table 6: Early childbirth by Education Level and Khyber Pakhtunkhwa 12.1 1.4 0.2 1.9 0.17 0.02 Balochistan 9.6 1.0 0.1 0.7 0.05 - Literacy Status, Age 18-22 (%) Gilgit Baltistan 9.2 1.3 0.2 1.2 0.15 0.02 18 years 15 years Islamabad (ICT) 2.8 0.3 - 0.4 0.05 0.01 H CMG SG H CMG SG Residence All 18-22 years 6.8 0.7 0.1 0.5 0.05 0.01 Urban 4.3 0.5 0.1 0.4 0.05 0.01 Education Rural 8.1 0.8 0.1 0.5 0.05 - No education 11.0 1.2 0.2 1.2 0.11 0.01 Source: Authors’ estimation. Values rounding to 0.0 not shown. Primary, some 9.8 0.9 0.1 0.2 0.02 - Primary, compl. 8.4 0.7 0.1 0.2 0.03 - Secondary, some 5.0 0.4 - - 0.01 - Rural girls are much more likely to have children early than Secondary, compl. 2.6 0.2 - - - - urban girls. Girls from the bottom four quintiles of wealth are Higher 0.8 0.1 - 0.1 0.01 - also more likely to have children early. The relationship Literacy between early childbirth, literacy, and education attainment is Cannot read 11.2 1.2 0.2 1.0 0.09 0.01 strong. Early childbirth measures are slightly higher for Limited ability 12.9 1.1 0.1 0.2 0.02 - women who work as compared to those who do not. Full sentence 3.6 0.3 - 0.2 0.02 - Source: Authors’ estimation. Values rounding to 0.0 not shown. Household welfare is measured through a wealth index with households categorized according to five quintiles of Table 7 provides data on labor force participation. One wealth. Women who had a birth tend to be married, hence would expect early childbirth to reduce women’s labor the level of wealth is that of the household in which the force participation, for example through higher fertility. But women married, not that of the household or origin. Yet if early childbirth is associated with poverty, women may the quintile of wealth after marriage and first birth may not leave little choice but to work. Other effects could also be be very different from that of the household of origin. On at work. In Pakistan, early childbirth measures are almost the other hand, since early childbirth measures are based slightly higher among women who work as compared to on young women ages 18-22, their level of assets may be those who do not, suggesting a positive association lower than would be the case later in life. In any case, the between early childbirth and work. However, the type of measures of early childbirth differ much by quintile, and it work associated most closely with early childbirth is work is only with the top two quintiles that early childbirth is with payment in both cash and kind, or without pay, which much less prevalent. may be work with low productivity. Table 5: Early childbirth by Quintile, Age 18-22 (%) Table 7: Early childbirth by Labor Force Participation 18 years 15 years Status, Age 18-22 (%) H CMG SG H CMG SG 18 years 15 years All 18-22 years 6.8 0.7 0.09 0.5 0.05 0.01 H CMG SG H CMG SG Wealth quintiles All 18-22 years 6.8 0.7 0.1 0.5 0.05 0.01 Poorest 12.8 1.3 0.17 1.1 0.10 0.01 Working Poorer 10.6 1.1 0.16 0.6 0.07 0.01 No 6.6 0.7 0.1 0.5 0.05 - Middle 7.4 0.8 0.10 0.5 0.06 0.01 yes 7.5 0.7 0.1 0.3 0.05 0.01 Richer 3.3 0.3 0.03 0.2 0.02 - Type of work Richest 2.0 0.2 0.02 0.1 0.01 - Not paid 9.0 0.6 - 0.2 0.01 - Source: Authors’ estimation. Values rounding to 0.0 not shown. Cash only 6.6 0.8 0.1 0.5 0.07 0.01 Cash and in-kind 13.9 0.8 0.1 - - - Early childbirth is associated with lower education In-kind only 6.3 0.4 - - - - Source: Authors’ estimation. Values rounding to 0.0 not shown. attainment, a lower likelihood of literacy, and (slightly) higher labor force participation. Table 6 provides data on early childbirth by level of education of the women, as well as literacy. Early childbirth affects education attainment negatively, because girls often drop out of school when they have Page 3 HNPGP Knowledge Brief  Conclusion The early childbirth gap represents the “depth” of early childbirth. It takes into account not only the share of girls who had their first This brief has provided a basic profile of early childbirth in child early, but also the mean number of years below 18 (or 15) Pakistan. Measures of early childbirth are high. The share at which girls had their first child. This matters because even if of women ages 18-22 who had their first child before 18 is the share of girls who have their first child early does not change, there may still be improvements in the early childbirth 6.8 percent and it has decreased over time. The share of gap if girls who have their first child early have that child a little women with their first child before 15 is at half a percent. less early. Early childbirth is associated with lower wealth and lower education levels, and higher labor force participation. Finally, the squared early childbirth gap measures the “severity” These are however only correlations, not necessarily of early childbirth. While the early childbirth gap takes into causal effects. Other briefs in this series look at potential account the average number of years of early marriage for girls causal effects. who have their first child early, the squared gap takes into account the square of that number, thereby putting more emphasis on girls who have their first child very early. Together References the three measures provide a better diagnostic of early childbirth than the headcount index alone. The measures also have Foster, J., J. Greer, and E. Thorbecke, 1984, A Class of attractive properties that are beyond the scope of this brief. Decomposable Poverty Measures, Econometrica 52: 761–776. The headcount index, early childbirth gap, and squared gap are Nguyen, M. C., and Q. Wodon, 2012, Measuring Child Marriage, the first three measures of the so-called FGT class (Foster et al., Economics Bulletin 32(1): 398-411. 2014). Denote by q the number of girls who have their first child early and by n the number of girls in the overall population. Annex: Methodological Note Denote by yi the age at which girl i had her first child and by z the age threshold defining early childbirth (18 years of age, but a While many studies have discussed trends in child marriage, lower age threshold such as 15 can also be used to measure less work has been done on trends in early childbirth. When extremely early childbirth). The general formula for the FGT conducted, measurement of early childbirth (or early pregnancy) class of measures depends on a parameter α which takes a has focused on one simple statistic such as the share of girls value of zero for the headcount, one for the early childbirth gap, who have a live birth before the age of 18 or 15. Such statistics and two for the squared gap in: are useful, but they do not capture well the distribution of the  1 q  z  yi   z  age at first birth in the form of aggregate statistics that tell us P  n i1  about the depth and severity of the problem. Basic statistics on the share of girls having an early childbirth also do not facilitate  testing for the robustness of comparisons of trends in early childbirth between countries, between groups within countries, or between time periods. This brief was produced as part of the Economic Impacts of Child Marriage study, a joint project of the International Center for Research Following the approach used by Ngyuen and Wodon (2012) for on Women (ICRW) and the World Bank, which is supported by the Bill & child marriage, this brief and its companion paper (available on Melinda Gates Foundation and the Children’s Investment Fund request) rely on methods from the poverty literature to measure Foundation (CIFF). More details on the research can be found at the project’s website: www.costsofchildmarriage.org. Partial funding for the early childbirth. Three measures are used: the incidence of early work related to child marriage and education, labor force participation, childbirth or headcount index, the early childbirth gap, and the earnings, and program responses has been provided by the Global squared early childbirth gap. The headcount index is simply the Partnership for Education. Comments from Jeff Edmeades and Michele share of the girls who have their first live birth before the age of Gragnolati are gratefully acknowledged. The opinions expressed in this 18. The headcount index can be computed for other age brief are those of the authors only and need not reflect the views of the thresholds, such as 15 years of age. World Bank, its Executive Directors, of the countries they represent. The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or disseminate new findings and lessons learned from the regions. For more information on this topic, go to: www.worldbank.org/health. Page 4